Forms

Reports

For sentinel events that occur on the premises of the facility that you represent, use these forms:

• If the sentinel event occurred on or after January 1st, 2012, please use the following form for part 1:
  • Part 1 Report Form (PDF)
• If the sentinel event occurred between January 1st, 2011 and December 31, 2011, please use the following form for part 1:
  • Part 1 Report Form (interactive Word)
• If the sentinel event occurred before January 1st, 2011, please use the following form for part 1:
  • Part 1 Report Form (interactive Word)
• For all sentinel events, please use the following form for part 2:
  • Part 2 Report Form (interactive Word)

• If the originating facility is:
  • a hosptial,
  • an obstetric center,
  • a surgical center for ambulatory patients, or
  • an independent center for emergency medical care,
  then notify the originating facility of the suspected sentinel event and inform the Health Division of the suspected sentinel event.
• If the originating facility is not one of the facility types noted above, then inform the Health Division of the event.

Summary Report

• Sentinel Event Report Summary Form (PDF)

Contact Information

• Sentinel Event Contact Form (PDF)

Some of the forms were created in Adobe's portable document format (PDF). These PDF files can be opened, completed, submitted, and printed using Adobe Reader. If you do not have Adobe Reader or its browser plug-in installed, visit Adobe's free download page .